Background: Up to 60% of bipolar disorder (BD) patients develop alcohol use disorders (AUD) at some point in their lives. The causes of this highly prevalent comorbidity are unknown. High trait impulsivity characterizes both isolated BD and AUD and may be a link to explain the association between BD and AUD. In this study, our aims were to investigate whether BD patients with comorbid AUD would present higher trait impulsivity levels compared to BD patients without comorbid AUD, and whether trait impulsivity levels differ within subgroups of BD according to the subcategory of AUD (abuse vs. dependence, alcoholism alone vs. alcoholism plus drug use disorders). Sampling and Methods: Forty-seven outpatients with BD with comorbid AUD (alcoholic BD group) were compared to 66 outpatients with BD alone (nonalcoholic BD group) and to 90 healthy controls (HC). BD and AUD diagnoses were obtained using the Structured Clinical Interview for DSM-IV diagnoses. Impulsivity was assessed using the Barratt Impulsiveness Scale (BIS-11), a self-report instrument that measures trait impulsivity in three domains: nonplanning, attentional and motor. Results: Alcoholic BD patients scored significantly higher than nonalcoholic BD and HC on the total and on each subscale BIS scores. Within the alcoholic BD patients, alcohol abusers and alcohol dependents did not statistically differ from each other on the BIS-11 scores. BD patients with AUD plus drug use disorders presented statistically higher nonplanning impulsivity than BD patients with AUD alone. Conclusions: This was a cross-sectional study and causal inferences about the relationship between impulsivity and the comorbidity phenomenon cannot be made. Increased impulsivity may be a trait marker for the co-occurrence between BD and AUD, and mediate some severe manifestations of this comorbidity.

Keywords:
Mood disorders, Alcoholism, Substance-related disorders , Comorbidity
1.
Eaton WW, Martins SS, Nestadt G, Bienvenu OJ, Clarke D, Alexandre P: The burden of mental disorders. Epidemiol Rev 2008;30:1-14.
2.
Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK: Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 1990;264:2511-2518.
3.
Feinman JA, Dunner DL: The effect of alcohol and substance abuse on the course of bipolar affective disorder. J Affect Disord 1996;37:43-49.
4.
Cassidy F, Ahearn EP, Carroll BJ: Substance abuse in bipolar disorder. Bipolar Disord 2001;3:181-188.
5.
Frye MA, Altshuler LL, McElroy SL, Suppes T, Keck PE, Denicoff K, Nolen WA, Kupka R, Leverich GS, Pollio C, Grunze H, Walden J, Post RM: Gender differences in prevalence, risk, and clinical correlates of alcoholism comorbidity in bipolar disorder. Am J Psychiatry 2003;160:883-889.
6.
Khalsa HM, Salvatore P, Hennen J, Baethge C, Tohen M, Baldessarini RJ: Suicidal events and accidents in 215 first-episode bipolar I disorder patients predictive factors. J Affect Disord 2008;106:179-184.
7.
Baldessarini RJ, Perry R, Pike J: Factors associated with treatment nonadherence among US bipolar disorder patients. Human Psychopharmacol 2008;23:95-105.
8.
Cardoso BM, Kauer-Sant'Anna M, Dias VV, Andreazza AC, Ceresér KM, Kapczinski F: The impact of co-morbid alcohol use disorder in bipolar patients. Alcohol 2008;42:451-457.
9.
Weiss RD, Ostacher MJ, Otto MW, Calabrese JR, Fossey M, Wisniewski SR, Bowden CL, Nierenberg AA, Pollack MH, Salloum IM, Simon NM, Thase ME, Sachs GS, STEP-BD Investigators: Does recovery from substance use disorder matter in patients with bipolar disorder? J Clin Psychiatry 2005;66:730-735.
10.
Gaudiano BA, Uebelacker LA, Miller IW: Impact of remitted substance use disorders on the future course of bipolar I disorder: findings from a clinical trial. Psychiatry Res 2008;160:63-71.
11.
Moeller FG, Barratt ES, Dougherty DM, Schmitz JM, Swann AC: Psychiatric aspects of impulsivity. Am J Psychiatry 2001;158:1783-1793.
12.
Najt P, Perez J, Sanches M, Peluso MA, Glahn D, Soares JC: Impulsivity and bipolar disorder. Eur Neuropsychopharmacol 2007;17:313-320.
13.
Bowden CL: Bipolar pathophysiology and development of improved treatments. Brain Res 2008;1235:92-97.
14.
Swann AC, Anderson JC, Dougherty DM, Moeller FG: Measurement of inter-episode impulsivity in bipolar disorder. Psychiatry Res 2001;101:195-197.
15.
Swann AC, Pazzaglia P, Nicholls A, Dougherty DM, Moeller FG: Impulsivity and phase of illness in bipolar disorder. J Affect Disord 2003;73:105-111.
16.
Swann AC, Dougherty DM, Pazzaglia PJ, Pham M, Moeller FG: Impulsivity: a link between bipolar disorder and substance abuse. Bipolar Disord 2004;6:204-212.
17.
Peluso MA, Hatch JP, Glahn DC, Monkul ES, Sanches M, Najt P, Bowden CL, Barratt ES, Soares JC: Trait impulsivity in patients with mood disorders. J Affect Disord 2007;100:227-231.
18.
Moeller FG, Dougherty DM, Barratt ES, Oderinde V, Mathias CW, Harper RA, Swann AC: Increased impulsivity in cocaine dependent subjects independent of antisocial personality disorder and aggression. Drug Alcohol Depend 2002;68:105-111.
19.
Dom G, D'Haene P, Hulstijn W, Sabbe B: Impulsivity in abstinent early- and late-onset alcoholics: differences in self-report measures and a discounting task. Addiction 2006;101:50-59.
20.
Chen AC, Porjesz B, Rangaswamy M, Kamarajan C, Tang Y, Jones KA, Chorlian DB, Stimus AT, Begleiter H: Reduced frontal lobe activity in subjects with high impulsivity and alcoholism. Alcohol Clin Exp Res 2007;31:156-165.
21.
Patton JH, Stanford MS, Barratt ES: Factor structure of the Barratt Impulsiveness Scale. J Clin Psychol 1995;51:768-774.
22.
Holmes KM, Bearden CE, Barguil M, Fonseca M, Monkul ES, Nery FG, Soares JC, Mintz J, Glahn DC: Conceptualizing impulsivity and risk taking in bipolar disorder: importance of alcohol abuse. Bipolar Disord 2009;11:33-40.
23.
Swann AC, Lijffijt M, Lane SD, Steinberg JL, Moeller FG: Increased trait-like impulsivity and course of illness in bipolar disorder. Bipolar Disord 2009;11:280-288.
24.
Hasin DS, Van Rossem R, McCloud S, Endicott J: Differentiating DSM-IV alcohol dependence and abuse by course: community heavy drinkers. J Subst Abuse 1997;9:127-135.
25.
Hasin D: Classification of alcohol use disorders. Alcohol Res Health 2003;27:5-17.
26.
McCown WG: Multi-impulsive personality disorder and multiple substance abuse: evidence from members of self-help groups. Br J Addict 1988;83:431-432.
27.
O'Boyle M, Barratt ES: Impulsivity and DSM-III-R personality disorders. Pers Individ Dif 1993;14:609-611.
28.
Kessler RC, Crum RM, Warner LA, Nelson CB, Schulenberg J, Anthony JC: Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Arch Gen Psychiatry 1997;54:313-321.
29.
Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Ruan WJ, Huang B: Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2005;66:1205-1215.
30.
First MB, Gibbon M, Spitzer RL, Williams JBW: Structured Clinical Interview for DSM-IV-TR Axis I Disorders. New York, Biometrics Research Department, NY State Psychiatric Institute, 2002.
31.
Hamilton M: Hamilton Psychiatric Rating Scale for Depression; in Guy W (ed): ECDEU Assessment Manual for Psychopharmacology. Washington, Department of Health, Education and Welfare, 1976, pp 179-192.
32.
Young RC, Biggs JT, Ziegler VE, Meyer DA: A rating scale for mania: reliability, validity and sensibility. Br J Psychiatry 1978;133:429-435.
33.
Strakowski SM, Fleck DE, DelBello MP, Adler CM, Shear PK, McElroy SL, Keck PE Jr, Moss Q, Cerullo MA, Kotwal R, Arndt S: Characterizing impulsivity in mania. Bipolar Disord 2009;11:41-51.
34.
Matsuo K, Nicoletti MA, Peluso MAM, Hatch JP, Nemoto K, Watanabe Y, Nery FG, Monkul ES, Soares JC: Anterior cingulate volumes associated with trait impulsivity in individuals with bipolar disorder. Bipolar Disord 2009;11:628-636.
35.
Matsuo K, Nicoletti M, Nemoto K, Hatch JP, Peluso MA, Nery FG, Soares JC: A voxel-based morphometry study of frontal gray matter correlates of impulsivity. Hum Brain Mapp 2009;30:1188-1195.
36.
Winstanley CA: The orbitofrontal cortex, impulsivity, and addiction: probing orbitofrontal dysfunction at the neural, neurochemical, and molecular level. Ann NY Acad Sci 2007;1121:639-655.
37.
Lewis M, Scott J, Frangou S: Impulsivity, personality and bipolar disorder. Eur Psychiatry 2009;24:464-409.
38.
van Gorp WG, Altshuler L, Theberge DC, Wilkins J, Dixon W: Cognitive impairment in euthymic bipolar patients with and without prior alcohol dependence. A preliminary study. Arch Gen Psychiatry 1998;55:41-46.
39.
Sanchez-Moreno J, Martinez-Aran A, Colom F, Scott J, Tabares-Seisdedos R, Sugranyes G, Torrent C, Daban C, Benabarre A, Goikolea JM, Franco C, Gonzalez-Pinto A, Avuso-Mateos JL, Vieta E: Neurocognitive dysfunctions in euthymic bipolar patients with and without prior history of alcohol use. J Clin Psychiatry 2009;70:1120-1127.
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